Nutrition [full issue]

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Yugoslavia: Dilavno Preduzeee Jugoslovenska Knigja, Terazije 27/II, Belgrade. Articles and photos not copyrighted may be reproduced provided the credit line reads " World Health". Please address enquiries to the Editor, WHO, Avenue Appia, Geneva, Switzerland. One year Two years Three years USA USA USA $ 5.00 $ 8.00 $10.00 UK UK UK 4.0 0.0 £2.12.0 Switzerland Switzerland Switzerland 12.- 22.- 30.- CONTENTS Half the world goes to bed hungry 3 10,000 years of food, by Lies! Graz 4 The stuff we are made of, by Noel West 9 Chicken for the millions, by Professor R. Ferrando 16 There are no harmless substances, by Linda Grace 20 One man's meat, by M. Rodinson 24 Food for the year 2,000, by Professor E. J. Bigwood . . . 27 Ocean harvest, by V. Bogorov and V. Stepanov 31 Book reviews 34 2 half the world goes to bed hungry As you sit facing your table this evening and begin to ladle out the food, you are composing a self-portrait. Your country, your income, your social class and your religion are mirrored in the food you eat, avoid, abhor or just can't afford, and the way you eat it. Furthermore, in the last third of the twentieth century, half the world is hungry and the other half tries hard to refuse the extra helping of fried potatoes or skip the rich dessert. Both halves have problems but it is obvious that the most serious ones confront the poorer nations. Protein-calorie deficiency, affecting mainly infants and young children, exists today in nearly every economically under-developed country. The results are a high mortality rate and a variety of defi- ciency-induced disease conditions. Kwashiorkor, beri-beri, deficiency- induced blindness are some of the striking results, but often the most insidious danger is the weakened wall of resistance in the child who succumbs to a common childhood ailment. Therefore the need to provide more food should go hand-in-hand with attention to the food's nutritional value and an attack on disease generally. People are emotionally attached to what they eat. Changing a man's meal seems to mean changing the man in some way. For example, if the protein lack were rife in Montreal or Manchester, instead of Africa and Asia, would a visiting group of foreign experts be able to persuade housewives there to introduce worms or snails, excellent sources of protein, in their diets? A change with far-reaching consequences is that away from breast- milk. Breast feeding is the only life insurance a child in a developing country has against disease and malnutrition. Yet urban ways of life, advertisements, or the mother's need to work away from home have resulted in a drop in breast feeding, with resultant ill-health and fatality. Often newer products, though less nutritious, are easier to prepare. Instead of pounding grain and then laboriously cooking a meal over small fire in an earthern pot, the mother simply opens a tin. Show- ing easier ways to cook or providing better utensils may sometimes do more to improve nutrition than general lectures and good advice. Food represents mother and the family; changing it may mean disloyalty or dislocation from the community. In all cultures eating is a positive act, not just a staving-off of hunger and malnutrition. WHO has often stressed that the best way to introduce changes in diet is to educate mothers, since what mother gives will eventually be perceived as right. Yet for all the reasons mentioned and many more, this is not easy. Mothers everywhere are subjected to a variety of influences and pressures. What is right must also be what respected people do and be available economically. If good foods are too expensive, it would be cruel to promote them. If only the poor are encouraged to buy them, pride will limit their use. Finally, mothers must have the time and energy to prepare proper meals. Special cases Another boomerang effect of progress has been advances which have permitted children in developing countries to survive who would have perished only a few years ago ... but only to survive. "A child aged six years, who at first sight may seem to be three because of physical under-development, cannot be compared with regard to conduct, psychology and learning capacity with a normal child of six, but also not with a child of three. He is a special case," states Dr J. Bengoa, Chief of WHO's nutrition unit. The malnourish- ed, undermined by repeated attacks of disease, are apathetic and almost never smile. Yet Dr Bengoa goes on to show how such children can be helped and can recover to an amazing degree through special nutrition rehabilitation centres. These centres provide sup- plementary feeding for children who are too well to be admitted to hospital and too ill to profit by school. In conclusion, there can be no single answer to the complex ques- tions involving nutrition, interwoven as they are with social beliefs, economic problems, and the prevalence of parasitic and other dis- eases. ■ 3 10 000 years of food by Lies! Graz Food has been described as the most stable element of culture. When a family emigrates, it will first change its habits of lodging, then clothing, then language. The last link with the old style of life remains the food it eats, the way food is prepared and even its psychological role; this food link sometimes continues for generations in the new home. And yet eating habits are not immu- table. Nowadays, a reference to Italian food invariably brings to mind the picture of a steaming platter of spaghetti covered with a fragrant sauce of tomatoes, garlic, herbs and olive oil. If spaghetti dates from the beginning of the 14th century when Marco Polo brought the recipe back to Venice after visiting the court of the Great Khan, the tomatoes are a modern addition. They came to Europe from the shores of North America in the 17th and 18th century. Known in England and France as "love apples", they were at first considered to be a violent aphrodisiac and not quite nice to serve, at least in a family setting. Even rice is not native to China. It probably originated in India and, although mentioned in the oldest Chinese literature, it became common about two thousand years ago. Before then, the staple was millet. Rice arrived in Japan eight or nine centuries later than in China. In the 19th century, the Japanese peasants still usually mixed it with two or three times its weight in barley, which was much cheaper. Never- theless, the three principal meals of the Japanese have long been known as asa- gozen, hiru-gozen and ya-gozen, morning- rice, midday-rice, evening-rice. The farming revolution In his earliest days, man was a food gatherer and only later did he become a hunter too. An almost unimaginable variety of foods have been gathered some- where in the world by some people or another. Some 10,000 years ago what is perhaps the most far-reaching revolution in the history of man took place : he became a farmer. Thus cities, commerce and complex civilization, all of which require stability based on a large, regular supply of food, could develop. Not, of course, everywhere at once. In northwestern Europe, it took until well after the Roman conquest to turn the natives into farmers. The Egyp- tians had very early turned from gathering papyrus and lotus to planting barley in the Nile Valley. The barley was used for both bread and beer. The relationship is not fortuitous. At first, the Egyptians made only a sort of porridge out of their barley, then flat cakes, baked on hot stones or in simple ovens. Once, somehow, barley- mash intended for beer making got mixed in with the batter. When the result was 4 I FL L_LJ-r- / -1 1 Li- 177- li 11-FL:LLL-1, II tiLLI41,- 1--- ----.. - .11 r Ai,FITI , Lii.LLI LI_LeJ I Lt-_.u , r 1 , i 1-1 iit 1 - 1 1 - ---4,-- ,- ,---_ i 1 ...„. I j -.— i 1 1-17. t 01*- -!....d....... ■ L tv 111 ig likt, ._ book—in northern Europe, salt together 011 with a little honey were almost the only flavourings. thrust into the oven by a thrifty baker- brewer (the two professions were usually exercised by the same man) the result was bread. The historical progression from gruel to cakes to bread can be seen in many different parts of the world; in some, as in the tortilla areas of Central America, the second step was never taken. Even in societies where raised bread was the rule, the idea remained that it was less holy than unleavened bread. For the Hebrews, the bread presented in sacrifice to Jehovah was always unleavened (even before the Exodus), and in ancient Rome the priest of Jupiter was forbidden to touch flour which had been in contact with leaven. The Eucharistic wafer of the Roman Cath- olic and certain other Christian churches is, of course, in the same tradition, al- though most Protestant and Orthodox churches use leavened communion bread. The reason behind this taboo may be found in the confusion between fermen- tation and putrefaction which was uni- versal until the time of Pasteur. Barley was the usual grain of the Egyptians until quite late in their history when it was replaced by wheat. The earliest home of wheat seems to have been somewhere in the Ethiopian highlands, ac- cording to Soviet geneticist Nikolai Vavilov, who bases his conclusion on the theory of gene centres: the earliest home of a given species is where the largest number of varieties can be found in the smallest area. Like the Egyptians, the inhabitants of Mesopotamia, the Sumerians, the Baby- lonians and the Assyrians, were primarily barley-eaters. Their daily menu also in- cluded vegetables and fruits : dates, pome- granates, turnips, cucumbers and an ample supply of garlic. A good number of calories seem to have been supplied by beer. Cuneiform tablets give a list of nineteen varieties brewed in Babylon and rations were regulated by social class : 1 quart to a field hand, 3 quarts for courtesans, 5 quarts for important officials. Cattle were kept for work, meat and milk. Sheep, goats (their milk was made into cheese) and swine were common. The Greeks were, on the whole, frugal and simple in their eating habits : coarse, heavy bread that would sink in liquid, a few simple vegetables, mainly turnips, cab- bages, cucumbers, leeks and garlic. As the population grew, the stony soil of the Greek peninsula and adjoining islands proved insufficient to provide the wheat needed. The necessity for keeping the trade routes open to the Black Sea was one of the causes of the incessant warfare of later Greek history. The search for rich corn- lands was also an important factor in the colonization of Sicily and it was there that Greek cookery became an art. In Sybaris, new recipes were "copyrighted" and re- mained the exclusive property of the inventor for a year. When the Romans crossed the Alps, they were appalled by the lack of good farming practices. The forests of northern Europe were sparsely populated and of- fered a good deal of nourishment to the peoples who lived in them, but there were some clearings planted with rye, millet, oats, barley and even a little wheat. To this day, the line where rye takes over from wheat as a major bread cereal runs almost exactly along the limes, the outer border of the "civilized" Roman colonies. The Germanic tribes drank a great deal of milk and kept large herds of scrawny cattle which were expected to forage for their own feed. In contrast to the Mediter - ranean peoples who used spices and herbs in large quantities and extraordinary com- binations—pepper, honey and salty fish concentrate are found together in almost every recipe in Apicius' Roman cook- The staff of life For most people the staff of life remains a cereal: wheat, rice, maize, millet, barley, oats or rye. But there are exceptions. The Huns and Mongols who swept out of central Asia in successive waves from the breakup of the Roman Empire until almost the end of the European Middle Ages lived largely on meat, mares' milk and cheese, some wild fruits and an occasional gruel of wild buckwheat. The buckwheat was neither winnowed nor ground; hulls and kernels were separated by repeated soaking and drying in the sun. Some of the inhabitants of the far north were, until quite recently, almost purely carnivorous. When Vilhjalmur Stefansson first met the Copper Eskimos south of Canada's Coronation Gulf in 1909, they felt it necessary to apologize for sometimes eating knotweed roots, which were not "proper human food". They only did so as a last resort just before they started to kill and eat their dogs, which was itself the last step before cannibalism. In northern Siberia, meat, especially reindeer meat, and fish on the coast, were the major sources of food for the Chukchis and their neighbours, but they varied their diet with the larvae of reindeer fleas, willow sprouts packed in brine and some flowers. Peoples whose staple was or is something other than a cereal are also found on South Sea islands and in large parts of Africa. In both parts of the world, some member of the manioc, taro, sweet-potato or yam family is the basic food. 5 Feast and famine Since the dawn of mankind people have often gone hungry. But transport and communications at different epochs have played a big role in alleviating or wors- ening the situation. The Phoenicians and the Romans transported great quantities of food supplies. Floating granaries brought wheat to Rome from Egypt and fat geese were moved from the banks of the Scheldt to the Imperial City. The whole breakdown of communications in the early Middle Ages and the new social structure deeply altered the food situation. A town could be starving while another, twenty miles away, enjoyed overflowing plenty. Feudalism gave the ownership of the land to nobles who had little or no interest in agriculture. Hunting was the sport of the nobility and many landowners would ride roughshod over ripening grain. There were at least fifteen periods of hunger in 13th century England, five in Germany and almost permanent famine in all of eastern Europe. The nobles and rich burghers did not often suffer from hunger. Indeed, over- eating was almost a status symbol and the nobles were often assigned gluttony as their particular deadly sin in medieval literature. The sheer quantities of food consumed are all the more impressive because the chroniclers assure us that everything was eaten (and not, as in the long procession of dishes on princely menus in 17th and 18th-century France, merely presented). We have the market list for the eight-day-long feast that master baker Veit Grundlinger of Augsburg, in Bavaria, gave for the marriage of his daughter in 1493. The 720 guests devoured 20 oxen, 49 goats, 300 fowl, 30 harts, 15 grouse, 46 fat calves, 900 sausages, 95 fat pigs, 1006 geese, 15,000 fish and unspecified quantities of dainties and salads. Food, climate and culture Food habits result from the interaction of climate and culture. Climate determines what is available and also to some extent what is necessary. The Eskimos and the Lapps could hardly go in for much agri- culture even if they were so inclined; fortunately a heavy dose of fat and pro- teins is just what they need in a very cold climate. More surprising is the traditional diet of Masai warriors of Kenya who lived, at least for a three-year-period, on milk, ox blood, half-raw meat and nothing else. Only women and old men were normally allowed to eat vegetable foods. However, the meat of the East African highlands was lean, not fat, and these dietary restrictions were limited in time. In some of the oases of the Sahara, the traditional menu was made up mainly of dates, with quantities that reliable sources report as high as 10 to 15 pounds a day for an able-bodied man. Such a diet was certainly excellent for the digestion but the bad teeth of oasis-dwellers were almost legendary as a result of such massive doses of sugar. An extraordinary number of food plants, commonly thought of as typically African, were brought from the Americas, mainly by Portuguese slave-runners. The botanical historian G. Schweinfurth estimated that some 30% of all plants now growing in Africa originally came from the other side of the Atlantic. These include maize, manioc, sweet potatoes, potatoes, Jeru- salem artichokes, sunflowers, arrow-root, all the members of the green bean family, tomatoes, groundnuts or peanuts, coco- nuts, pineapples, peppers, vanilla and cacao. The introduction to Europe and the rest of the world of maize and potatoes has done more to change eating habits than anything else. When the Europeans arrived in the Americas they found, in the low- lands, a civilization almost entirely based on maize a marvellous cereal. Maize requires no deep plowing and harrowing, comparatively little seed, almost no weed- ing or complicated implements and grows very rapidly. It was enthusiastically ac- cepted by the Moslem populations of Africa and Asia who saw it as the plant of Paradise mentioned by the Prophet : it seemed to grow in the wink of an eye. The Turks bought seed from the Vene- tians and by the time a German traveller reached the banks of the Euphrates in 1594 he could report that "there is nothing to be seen but fields of maize". Maize has only one real defect: it is woefully lacking in several essential nutrients. On Otailtr-os le por mollur POarlf, a Gr trUlflflP iraii 6 bruy6r1 r A 16th-century Flemish print attributed to Brueghel. As late as the nineteenth century, oysters were the poor man's dish in Europe. Dickens' Sam Weller says, "Poverty and oysters always seem to go together. Blessed if I don't think that ven a man's wery poor, he rushes out of his lodgins, and eats oysters in reg'lar desperation." ti mare conuiu,- Darr inajferm an A' pot meter is ern arm A-71.1r ue it rcitire dos _by irk nae de urttr ateden met ferten Nye 7 Health without meat One can be perfectly healthy on a vegetarian diet. Trappist monks who lead a hard life of physical work and sleep interrupted by frequent services, with the additional hardship of perfect silence, have been exam- ined repeatedly and are usually found to enjoy excellent health, after a period of adaptation, and have an average life-span a little higher than their secular counterparts. The Trap- pist diet consists of bread (wheat and rye), gruel, legumes, fruits, vegetables and milk—but no eggs. An even stricter vegetarian diet, followed in other parts of the world that excludes products of animal origin altogether, becomes very difficult to balance. Although legumes, nuts and soya beans all contain considerable quan- tities of protein, it is very hard to consume the sheer quantities needed. In the valleys of the Andes the staple is the potato and has been for thousands of years. At high altitudes the growing season is short and some provision must be made for preserving food. More than 2,000 years ago the Andean Indians were preparing chuno, which can be described as a form of freeze-dried potatoes. The tubers are cut into thin slices and spread out to freeze in the night. The next morning they are trodden with the feet to remove as much moisture as possible and left to dry in the bright mountain sun. The process is re- peated several times until the resulting product can be kept for months and even years. The exact details of the arrival of the potato in Europe and Africa from its American home are still disputed. How- ever, the legend crediting Sir Walter Ra- leigh with having found the potato in Virginia and introducing it into England is certainly false. There were no cultivated potatoes in North America when the first colonists arrived. The potato was probably introduced into Europe by way of Spain, sometime between 1550 and 1570. The sweet potato, which is not related botan- ically to its homonym, was brought to Spain within 12 months of Columbus' discovery of Haiti, in 1493, and quickly adopted as regular ships' stores by his successors. Foods and fads One of the principal origins of food fads can be found in the theory of humours, by which every substance and every living creature is, in varying degrees, moist, dry, hot and/or cold. In 17th-century England, while Harvey was explaining the circula- tion of the blood, Thomas Muffett, a medical man and dietary authority was able to write, seriously, "Yea, my self have known a young Maid, of an exceeding moist and cold complexion, whose meat for two years was chiefly pepper, where- with another would have been consumed, though she was nourished, for it is hot in the third and dry in the fourth degree". The theory of phytognomonica, a strik- ing example of anthropomorphism, first expounded by Giambattista Porta of Naples in 1588, contended that eating long- lived plants would lengthen life while eating short-lived plants would shorten it; plants with yellow sap could cure jaundice, those with a rough surface heal skin diseases all of this medicine to be taken internally. The theory was further devel- oped over the next century and the English Dr William Coles recommended eating walnuts as a cure for troubles of the brain. Although there have been vegetarians for religious and philosophical reasons in many parts of the world for thousands of years, one of the first European theorists of secular vegetarianism was the Reverend William Metcalf, who published his Absti- nence from the Flesh of Animals in 1821. He was quickly eclipsed by his American fellow-clergyman, the Reverend Sylvester Graham, whose vigorous campaign for vegetarianism and wholesome bread has been perpetuated in the crackers and flour that bear his name. Chewing craze In the early years of this century an American named Horace Fletcher explain- ed that all our health problems were the result of insufficient chewing of food and recommended masticating every mouthful until it was reduced to a fine liquid. Although this would have meant devoting a good part of the day to chewing, the idea that Europeans and Americans should use their teeth and gums more intensively was a good one. Theoretical food fads of this sort are one thing, but another group of food promotors also have something to sell. There was a wheat-germ-and-yoghurt craze, then honey and vinegar were the thing; there are still people who explain that it's best to "drink your vitamins" and are ready to sell a liquidizer, which is in itself expensive, to turn 8 pounds of carrots into the recommended 2 quarts of juice a day. Blackstrap molasses had its heyday a few years ago; the food-fad people had found an expensive way to sell a cheap by-product, the last dregs of sugar re- fining, by proclaiming it to be good for most of mankind's ailments, especially anae- mia and rheumatism. While it is true that blackstrap molasses contains some cal- cium and iron, most of it by contamination from the metal machinery in the food- processing plants, other products contain it as well. Fad products are often not harmful in themselves. In fact, many of the so-called "nature" foods are excellent. What may be harmful is the fact that people often trust in their magic instead of taking themselves and their symptoms to a competent doctor; there is also the burden they place on the family budget because of their excessive cost. Food preservation Having enough to eat all the year round has always raised the problem of storing food, at least from one season to the next, and the search for new, easily stored and transported foodstuffs still goes on. In Europe, lengthy ships' voyages to the East Indies and Americas were the stimu- lus needed to begin serious experimenta- tion with preserving food. Salting, pickling and drying had long been used and, in the 17th century, Robert Boyle came up with a recipe to keep meat during the East India voyage : roast the meat, cut it into small pieces, pack tightly in casks and fill the air space completely with melted but- ter. The meat kept well for 6 months. Captain Cook took cases of "portable soup" on his voyage around the world in 1772; it looked like a slab of glue, was probably made by evaporating a clear broth and, when mixed with pease flour and water, provided excellent nourish- ment. An important invention was that of Nicolas Appert, who won a prize of 12,000 gold francs when the French navy adopted his principle of canning food in 1809. Every time a housewife puts up peaches in glass vacuum jars today, she is following the Appert process, only slightly modified, although the reason it worked was never known to the inventor. Today, research for space travel has produced extraordinary compounds to feed the astronauts with a minimum of bulk and preparation. Inevitably we imag- ine a future where, except for occasional solemn banquets, we will live on a few pills containing all the minerals, vitamins, calories and so on needed by the human body. But surely the art of cooking a good steak with a dab of bearnaise sauce, a refined couscous or a hearty curry will never be lost because of all the pleasure they bring. ■ 8 the stuff we are made of by Noel West Nutrition has been defined as food plus all that happens to it from the time it is eaten until it nourishes the body. No one needs to read a book or even be told that without food life stops. We are all born hungry. But proper nutrition is complicated, and we are still learning about it and the role it plays in allowing man to work, think and resist disease. If you set fire to food it will burn. You can run a steam engine on dry milk and beans. Thus, food releases energy and gives off heat; it really is "burned up" in the body or metabol- ized. This energy allows our body to perform work and sustain itself. The calorie is simply the measure of heat energy. A calorie represents the amount of heat required to raise the temperature of a kilo of water by one degree centigrade. Thus a calorie is not a nutrient but a unit of energy derived from food. This energy value of the food we eat is either stored as body fat or burned to produce heat and muscular work which is also cal- culated as heat. The basic nutrients used this way are carbohydrates, fats and protein, represented in rather pure forms by sugar and corn- starch, lard and salad-oil, cottage cheese and egg-white respectively. All nutrients do not have the same caloric value : 1 gram of carbohy- drate yields about 4 calories as does one gram of protein but 1 gram of fat yields 9, which is why people trying to reduce should shun fats and see an enemy in a thick smear of butter or a fried potato. Yet these three 9 nutrients are essential and each has a different function to perform. The roles they play Carbohydrates: These are derived from sugars and compounds of sugar groups. Almost invariably they come from plants, with the notable excep- tion of milk sugar, lactose. In this group are the starches; rice, grains, potatoes are large sources. In fact, the staff of life, whatever it is, tends to be composed of carbohydrates. Refined sugar is a concentrated form of carbohydrate often eaten as jam, marmalade and candy (which is pure sugar). Many natural foods, on the other hand, though rich in carbohydrates contain proteins as well. In their dried form, beans and peas are 60 % starch but still contain 20 % protein; soy beans may have up to 35 % protein. One reason carbohydrates are the staff of life is simple : they are cheap. Such foods as bread, rice, potatoes and corn form the weighty centre of meals in every country where price is still a large factor in determining diet. Although the body has no fixed requirements for carbohydrates, they do provide energy and flavour, and foods that contain them may also provide vitamins and minerals. Fats: Fats are in the middle of a raging, boiling if you prefer, contro- versy. They have been accused of playing an important part in pre-dis- posing to heart diseases. Although this is debatable, fats are the most highly concentrated source of calo- ries; so they are most indictible for making us overweight and certainly obesity is a grievous thing. However, some fatty acids are essential. Also vitamins A and D are usually only found in fats. Besides, fats taste so good. Fats make bread and salad taste better, and often stave off hunger pangs the longest. They protect us against the cold and have high energy value. They are also the simplest animal way of storing energy. Butter, lard, fish livers and egg yolk are all rich sources of fat. Plants store fats in their seeds and kernel; sunflower seeds, corn and wheat germ are plant sources of fat. Few fruits are fatty : avocados and olives are the notable exceptions. Proteins: Life without proteins is not possible, no matter how much carbohydrate or fat you may eat. Proteins form part of every cell in the body, the body fluids, the skin and even the hair and nails. They are a good but expensive source of cal- ories. Furthermore, some proteins, such as those provided by meat, milk, eggs and fish, are more efficient at reconstituting body tissues. How- ever, they are expensive. Here are the elements of a tragedy being enact- ed on our planet's surface involving hundreds of millions of men, women and children. We obtain protein directly from plant foods or indirectly through eat- ing animals which have already form- ed protein from plants. There are 22 commonly found amino acids, components of protein, of which ten are termed essential. Not all proteins are as completely usable in the hu- man body as others, and therefore they differ in nutritional value. Pro- teins carry valuable minerals and B Meat is one the best sources of high-grade protein. 10 Sausages are rich in fats and protein. Fruit should form an important part of any diet. Nuts provide proteins and fats. 11 complex vitamins, and serve as fuel if the body lacks other sources. The problem in poor countries is that protein is expensive and that other sources of protein are being neglected. People may eat manioc because it is easy to grow but it con- tains only 5 % protein. The nutritio- nal crisis today is not simply hunger but "protein-calorie-malnutrition". Minerals: There are many minerals in food and some play important roles. Calcium and phosphorus are needed for bones and teeth and, though they are present in many foods, they are rich in few. Milk is an especially good source although some green vegetables also supply them. An adult needs about the equi- valent of 3 cups of milk each day; pregnant women in the second half of pregnancy almost double that amount. Eating fish, bones and all, or soaking foods in limewater helps provide calcium. Sugar and butter provide none. Only a little iron is needed in the body but its role is vital ; over 60 % of the body's total iron content is in the haemoglobin of the red blood cells. A shortage of iron is one of the major causes of anaemia (see World Health June 1968). Iron is supplied by meat and dry legumes, but can also be obtained from dark green leafy vegetables (Popeye knew this too), egg yolks and whole grain cereals. Vitamins are now the latest of the known nutrients. A dozen or more occur naturally in food and contrib- ute to human nutrition. They do not furnish energy but are essential and have specific jobs to do. They cannot be made by the body itself and so must be obtained from foods. How- ever, good diets don't need vitamin supplements. There are two vitamins that are especially important: vitamin A and vitamin B1 or thiamine. Vitamin A is present only in animal foods and is needed for good vision, especially at night, and to resist infection. It also helps body growth. Foods rich in vitamin A are usually yellow—egg yolks, fish-liver, butter. Carotene, The toddler must stand off a siege of childhood diseases, diarrhoeas and parasites with the slender forces of his body. Malnutrition lets the enemies in. which can be converted into vitamin A, is found in a number of vegeta- bles such as carrots, sweet potatoes and some dark green vegetables. Vitamin B1 is required for the proper use of carbohydrate in the body. It is present in meats and grains. Since most of mankind eats far more grain than meat it is vital to see that the vitamin is not lost: ironically, some modern methods of processing food result in less vitamins. When rice or grains were pounded and milled by hand, much of the vitamin-bearing husk and germ remained. Machine milling and rice-polishing remove most of the vitamin B1 and present the consumer with an appetizing food stripped of valuable elements. When the body lacks what it needs Although half the world may be hungry, hunger itself can take many forms. A poorly balanced diet which may be high in carbohydrates, in order to stave off hunger pangs, may result in conditions as serious as protein-calo- rie malnutrition or marasmus, and the absence of certain elements such as vitamins or minerals can result in specific diseases. Furthermore, a poor diet rarely occurs alone but is usually accompanied and aggravated by pa- rasites and infectious diseases of all sorts. Thus, simple "childhood ail- ments" which are perhaps inevitable in a normal child's growth frequently prove fatal to the fragile health of a malnourished child. The following are some major ail- ments caused by dietary deficiency : The term "protein-calorie malnu- trition" of early childhood has been suggested to cover the whole range of classifiable and unclassifiable manifestations of inadequate protein- calorie intake. The two major severe illnesses are kwashiorkor and nu- tritional marasmus. Nutritional ma- rasmus describes the condition of infants "who are suffering essentially from starvation". Associated with diarrhoeal disease, nutritional maras- mus is increasing in artificially-fed 12 These 3-year-olds are suffering from marasmus. Only the first child is able to stand upright without assistance. The most vulnerable age, nutri- tionally speaking, is one to five years. It is important that the diet, rich in carbohydrates, pro- vide the child with the protein and vitamins he needs. infants in urban areas of developing countries. Kwashiorkor, which means a disease caused when another child is born, is rarely exclusively dietary in origin. Infection and other con- ditioning factors are operative in its onset. Kwashiorkor occurs most commonly in the second and third years of life, when protein require- ments are especially high. A con- tributing factor has been the switch- over in many countries to the pro- duction of high-calorie carbohydrate foods, such as cassava, which are easy to grow and often replace better foods. Ignorance plays a large role. There may be prolonged dietary restrictions or use of purges in diarrhoeal disease. Cattle may be prized as symbols of wealth rather than for milk yield. Animal protein may be reserved for older males, who need it least. Carbo- hydrates may be over-valued for in- fant food. Sometimes malnutrition and over-feeding go hand-in-hand, since the child may be over-fed with cheap carbohydrates. A child, even an infant, is more than a body. It is also a mind and personality. An under-nourished child has a face suggesting a mask rather than a human being. The child remains immobile, unreacting. He may even refuse food and whimper at the least touch. The easiest, sim- plest test of his recovery any parent would guess : as soon as the infant smiles, full recovery is almost as- sured. Treatment involves finding a digest- ible diet containing protein, calories and other necessary nutrients. It in- volves treating infections, and must not exclude tender loving care, or what is termed "educational psycho- therapy". Finally, the mothers need to be taught to feed their children in such a way as to prevent re- lapse. Avitaminosis A has been found all over the world, but seems to be par- ticularly prevalent in South-East Asia, where it is an important cause of blindness. One writer is of the opi- nion that about sixty per cent of the blindness in Ceylon and South India is produced by lack of vitamin A. Nutritional eye-disease is often overlooked, and is associated, un- fortunately, with poverty and igno- rance. Infantile beri-beri This disease occurs as a result of a thiamine (B1) deficiency. Sometimes the onset is sudden. "A baby around three months old, apparently in good health, nursed entirely by its mother, is abruptly seized with an attack of screaming. As he utters his loud pier- cing cry, his body stretches, the abdo- men becomes hard, the pulse thready, the respiration laboured, his face either deathly white or cyanotic, and an expression of profound terror or suffering grips his entire being. This state may last anywhere from one half to one hour. It disappears spontan- eously, only to recur with increasing severity and frequency until death supervenes, or the specific treatment is promptly administered." Curative treatment may consist simply in giving thiamin hydrochloride intrave- nously as soon as possible, and then seeing that the child gets a sufficient supply of the thiamine in his food. This disease is most widespread and serious where people use pol- ished white rice as a staple food. Rickets Vitamin D, the lack of which pro- duces rickets, is produced naturally by irradiation of the skin with ultra- violet-light. The sun gives us all we need. However, natural vitamin D is also present in butter, egg yolk, fish- liver oils and milk. Rickets was first known as a disease of northern coun- tries where sun was scarce, and housing and living conditions made access to it difficult and infrequent. Ironically, the major centres of rick- ets today are areas in the subtropics where infants do not receive sunlight because of cultural reasons. In some countries of North Africa, for ex- ample, about forty per cent of chil- dren admitted to hospital show some evidence of rickets. The reason for this, in countries where sunshine is so dramatically evident, resides in the fact that children are often kept out of the light, or live in dark alleys and courtyards. Remedies would seem to be cod liver oil for children who live in the north, and simply more exposure to the sun for child- ren nearer the equator. Poverty and ignorance All the conditions described are a result of many factors which are large in scope and difficult to remedy, espe- cially poverty and ignorance. Only when people know what they should eat and are able either to grow it or pay for it will one of the major scandals of our century be eliminated. This is a concern that should touch all of us. ■ 14 the importance of being mother "All over the world new sources of protein are being sought to try and fill what is currently termed 'the protein gap', yet at the same time the major source of consumer-tested protein infant food—maternal milk—is tending to be disregarded." Furthermore, an important and dangerous trend is noticeable all over the world among mothers in lower economic groups living in urban areas. Children tend to be weaned earlier and given increasingly unsatis- factory food to replace mother's milk. In his book, "Infant Nutri- tion in the Sub-Tropics and Tropics", published by WHO, Dr D.B. Jelliffe emphasizes the irony of the fact that many social changes in the developing nations of the world, instead of improving nutrition, are actually worsening the situation. The trend towards bottle-feeding and early weaning has as its result much illness and mortality among infants in tropical areas. One cardinal rule seems to apply, namely "breast milk is the most suitable food for human infants under all circumstan- ces". Nor is this food important only in a physiological sense, "for the truth is that, for babe or man, there is no warmth or security to be found in a bottle. There is only one thing to do with it, and that is to empty it." Dr Jelliffe is convinced that the use of powdered or tinned milk is often ill-advised. What may be accessible to wealthier classes is out of the question for poor people, and they are the ones who suffer most from malnutrition. They have no refrigerators, clean water, adequate storage space or even enough money to buy milk in sufficient quantities to make it worthwhile. To bottle-feed a four-month baby in East Africa costs about a third to a quarter of a labourer's total earnings. Preparing milk in the average con- ditions of a dirty fly-ridden kitchen with dubious water supply makes it a potentially dangerous fluid. Yet, as urbanism rapidly increases, so does this practice. Weaning can be a very dangerous period. Nearly always an infant is given the softest, starchiest portion of the adult diet as its first food; too often this is unsuitable and indigestible. The change may also be abrupt and the infant restricted to a single, predomin- antly carbohydrate food. Dr Jelliffe's book is rich in examples of the cultural practices surrounding nutrition in countries as far removed as Morocco, Thailand, Mexico and Uganda. He not only points out the negative influence of certain food taboos which restrict needed proteins for mothers and children or allow rickets to develop in a sunny country, but also suggests a variety of positive measures. For example, the easiest and most inexpensive manner of ensuring adequate vitamin D is by putting the baby out to sunbathe daily. Food changes should be introduced within the general frame- work of the cultural conditions; that is to say, it is better to enrich a local food than to try to substitute something else. Finally, Dr Jelliffe stresses that changes in eating patterns represent only some of many changes taking place in a dynamic social context. Sweet drinks or white flour may compete with nutritionally desirable food that just doesn't appeal to people or, rather, is not presented correctly. However, one thing is certain : concrete results such as gaining weight, feeling better, being more cheerful and active are undeniable proofs that better nu- trition is a valuable investment in any culture. ■ chicken for the millions by Professor R. Ferrando Many people are concerned about products that are added to food in order to increase production. In this interview, Professor R. Ferrando, Director of the Food and Nutrition Laboratory of the National Veterinary School, Alfort, France, discusses some of these practices and the safeguards now in use. W.H.: Nowadays, those who raise poultry and pigs use antibiotics and various chemicals as a regular prac- tice. Although done to increase the animals' growth or to prevent dis- ease, does this not present some dan- gers for the consumer? Prof. Ferrando: Raising animals and poultry today is not what it used to be ; techniques have evolved and improved. You may say it is collective, not in the economic sense of the term, but hygienically. Instead of raising a few pigs or chickens, thousands are brought together in the same place where they are subject to a variety of influences from the environment and run a high risk from a number of contagious dis- eases, which is why they need special protection. It seems to me that meat from sick animals is far more dan- gerous for the consumer than from those that have received infinitesi- mally small quantities of certain sub- stances to increase growth or protect against parasitic diseases such as coc- cidiosis which attacks chickens. In fact, without these remedies to coc- cidiosis it wouldn't even be practical to carry on mass methods of poultry farming. On the other hand, the in- crease in human population makes such forms of production necessary, since more and more consumers need an ever larger quantity of protein. As you know, the world is suffering from protein hunger. The other aspect of the problem consists in making proteins inex- pensive enough to be available. If old-fashioned farming methods were to continue, meat would be exces- sively expensive. You do hear, how- ever, a lot of old wives' tales about chickens, particularly those treated with hormones ; they are even a standard subject for jokes in France. However, hormones have never been authorized in France and this prohi- bition has been strictly maintained. I think it is only fair to say that the products we consume today are just as good in quality as those in days gone by: various experiments have proved this. W.H.: Nevertheless, some people say that chicken doesn't taste as good as it used to. Prof Ferrando: The change in taste is probably due to poor slaughtering methods. In order to pluck chickens they wet them. Yet I remember as a 16 Old-fashioned farming still retains its charm but only modern methods of mass- producing meat can satisfy the hunger of the urban millions. France. ► In this co-operative farm in Hungary 11,000 chickens are being raised for market. 17 child, my mother told me that when you killed a chicken it was important not to wet it in order to pluck the feathers because that gave a bad taste. In any case, the taste of poultry is not affected by additives. W.H.: What are the checks for quality control of products used in animal farming? Prof Ferrando: The process of having a product accepted in France is quite a long and complicated one. First of all, a file is submitted to an interministerial and interprofessional committee dealing with animal foods, which I have the honour to preside. It includes about 30 people, among them doctors, pharmacists and tox- icologists. First of all the product has to present certain obvious advan- tages ; ability to increase growth or general usefulness in raising animals, efficiency, economy and harmlessness for the animal. If these conditions are met the next question is to deter- mine its harmlessness for the con- sumer. Such studies take place on various levels : for example, the met- abolic processes of the animal; we find out how much goes in and how much goes out, to determine how much remains in the animal's organism. Often the balance is nil, that is to say everything passes through quickly. There are cases, however, where traces of the sub- stance remain. Then a study is made of its toxicity. Only after a series of examinations is completed can a de- cision be taken. In France, the rap- porteur, who has all the findings of these tests carried out in official ex- perimental stations supervised by tox- icologists and pharmalogical experts who are members of the intermini- sterial commission, can at any time request that the experiments be star- ted over. Files on the experiments are, in fact, as detailed and complete as those presented to the Pharma- cology Committee whose job it is to pass on new medicines. Furthermore, these authorizations are only issued for determined doses of the additive, for example, 5 to 20 milligrams per kilo of food. The quantities therefore are very small. As soon as residues amount to more than one milligram per kilo of meat we refuse to accept the substance. Take for example the average Eu- ropean, who eats about 20 to 22 kilos of chicken a year. This means that the consumer would only absorb two dozen milligrams a year at the most, certainly not a serious state of affairs. Furthermore, no one eats chicken or pork every day and so this con- sumption is spread out over the year. Let me add that an authorization is granted for only one year at a time and must be renewed. Moreover, if a new factor intervenes we can recon- sider the question at any time. Fur- thermore, even when an authoriza- tion has been given, a check-up is still carried out, by the authority responsible for the prevention of fraudulent practices, to find out if the rules are being followed. The only real danger at the mo- ment are salesmen who, in many countries where veterinary pharma- cology is not strictly controlled, sell a variety of products without any control at all. However, one built-in safeguard is the fact that farmers are usually rather thrifty—some would go so far as to say downright stingy —and these additives usually cost quite a bit. Furthermore, adding these products to foods usually re- quires complicated installations. W.H.: What is the situation in the other countries of Europe? Prof Ferrando: Generally speak- ing, all European countries follow the same norms. What is more, we are presently at work trying to reach an agreement concerning allowable food additives and substances for all countries or at least several of them; the eventual goal will be uniform standards. In fact, there are a number of expert committees now at work within the European Economic Com- munity. W.H.: What sort of check is there on food imports? Prof Ferrando: Countries who sup- ply us with meat, particularly pork and chicken, have controls of their own and, if French regulations are strict, they are certainly no more so than those of Denmark or the Food and Drug Administration of the United States. Furthermore, feed ad- ditives are not used for beef cattle or sheep. W.H.: In your work, it is obvious that the role of the laboratories is expanding but what trends do you notice? Prof Ferrando: Chemistry and biochemistry are constantly evolving. Organic synthesis proceeds more rap- idly than laws and regulations but it is obvious that we will have to cope with these questions because a thou- sand substances must be studied in order to find one that is valid and meets the norms I have indicated. You could say that life is evolving constantly and we must try to stick as close to it as we can. ■ 18 Controlling the temperature of chicken-hatcheries in the state farm in Boly/Comitat Baranya, Hungary. ► This automatic machine washes and disinfects eggs. It can clean 10,000 eggs per hour. The process protects the chick embryos from infection by cleansing the egg-shells of bacteria. Hungary. y 19 there are no harmless by Linda Grace Food additives, says the man in the street, are a bad thing; but it all depends on what you mean, for every time a cod is salted or a cucumber pickled, the salt or vinegar, in a sense, is a food additive. But there is also the official definition of a food additive adopted by FAO and wilo : "a non-nutritive substance added intention- ally to food; generally in small quantities, to improve its appearance, flavour, texture or storage properties." Appearance of food might be thought to be least important, but not so by com- mercial food processors. Over the past century, consumers have become increas- ingly discerning. Dill pickles or canned peas may be just as tasty when their colour is greyish green, but the consumer pre- fers bright green colours which neces- sitate additives. The introduction of super- markets and self-service shops in many countries and the development of mod- ern transparent plastic containers have made the appearance of food more im- portant in influencing the buyer's choice. Yet appearance can deceive, even dan- gerously. English toffees and boiled sweets are still famous, but they no longer have the bright colours that were the hallmark of "London sweets" at the end of the 19th century: most of the bright colours used then contained lead pigments. The increasing use of flavouring agents in food processing had led to much dis- cussion and extensive legislation. The problem often concerns the distinction between natural and artificial flavours. Chemists have identified the chemical compounds responsible for the flavour of many natural foods. y-undecalactone, which is the major constituent of peach and apricot flavour, had been synthesized in the laboratory for some years before it was discovered that it also existed in natural fruits. Food chemists will explain that it is cheaper and more effective to use synthetic and pure undecalactone than to use fresh peaches, which may have been sprayed with certain pesticides or tainted with rot. As for the vitamins naturally present in peaches, the same chemists may explain that their natural concentrations are negligible in commercial ice-cream or pastry and may therefore be replaced by appropriate amounts of synthetic vita- mins. The use of food additives to improve texture is another development of the processing industry in deference to con- sumer demand. Emulsifiers are the com- monest additives in use. They ensure that mayonnaise and margarines retain their smoothness for months, and impart to Publications of FAO and WHO on additives. substances commercial whipped-cream toppings their velvety texture and capacity to retain shape. Other additives prevent the caking of granulated food, the separation of emulsions or their formation. Wastage and shortage In some cases, little distinguishes the additives used to improve texture from those which enhance the keeping qualities. Better storage conditions are essential if more food is to be provided for the mil- lions of people in the world who are undernourished. A group of experts meet- ing under the auspices of WHO estimated that about 20% of the world's food is lost through waste and spoilage. Food preservation is often a race against time : fresh meat, fish or poultry will keep at most one or two days at room tem- perature : after that, deterioration is rapid. Dried, salted or canned meat and fish may be kept for a year or more. Fresh ripe fruit will spoil in a day or, at best, after a week; dried fruits will keep for over a year. Even untreated root crops are at their best for only one to three weeks : after that, they will soften and sprout. All manner of things may be added to food for preservation. We know from long experience and experimentation that some are innocuous. It all depends on the dose ingested; even ordinary salt may be harm- ful in excess. But the more foods are treated, the greater the chance of two or more preservatives being used. They may be metabolized at different rates and may, possibly, have a synergistic action. Most processes of food preservation aim mainly at the control of the microbial spoilage. Heat or irradiation can destroy micro-organisms; cold or dehydration will retard the growth of many. High concen- trations of sugar, salt or vinegar will also inhibit their growth as will certain preservatives added to meat, fish and poultry. However, there is the possiblity of enlisting the aid of useful micro- organisms which ferment cheese, sauer- kraut, beer or wine. Sometimes several methods are in use. Ham, for instance, is usually salted, often partially cooked or smoked, and then treated with small amounts of nitrite. One of the major principles guiding the use of food additives is to employ the minimum quantity needed to produce the desired effect. Research is being carried out to discover preservatives that will be self-eliminating: they should kill harmful Consumers prefer margarine that does not run, and peas and pickles that are green. These qualities are obtained by additives. bacteria and then disappear without leav- ing any residues. There is no justification for using ad- ditives of doubtful safety. In most cases alternatives are available. The selected additive may not fulfill all the technolog- ical requirements, but there should be no health hazards arising from its use. This principle is widely applied today. Agene was used for many years as a bleaching and improving agent for flour. When it was shown to cause convulsions in experi- mental animals, its use was abandoned by the millers. Other bleaching agents are available and there was no need, therefore, to continue with one shown to possess certain toxic properties. Food adulteration and contamination In the past, the use of food additives was synonymous with food adulteration. The forerunners of public analysts in Britain were the beer tasters who spilled a little beer or ale on a wooden bench and then sat on it until it dried. If their leather breeches stuck to the bench, it was con- sidered proof that the beer had been adulterated by the addition of sugar. When industrial food processing began on a large scale in the last century, unscru- pulous chemists had a field day. Not only lead, but mercury, arsenic and copper salts were common colouring materials; form- aldehyde and hydrogen peroxide were used as preservatives and considered for a long time by some to be preferable to pasteuri- zation of milk. Falsification and adulteration are com- paratively rare today. Manufacturers of strawberry jam may use high-grade straw- berries and sugar, or they may use pectin and strawberry aldehyde and pumpkin chunks—and call it artificial strawberry jam. Neither of these extremes causes diffi- culties, which may, however, arise when a manufacturer uses low-grade strawberries, a little pectin, colouring matter, and a small amount of artificial flavouring. He is unlikely to label the result artificial strawberry jam. The need for adequate labelling is, therefore, one of the major concerns of consumers' associations, and such associations are usually encouraged by government authorities responsible for food safety. But for this protection to be effective, consumers must have more than a rudi- mentary knowledge of the meaning of such terms as "natural" and "artificial". Many people have an inherent dislike of anything artificial, especially in food, and yet, as in the case of peach flavour, the synthetic material often is identical in chemical structure with the natural pro- duct, but offers possibilities far beyond the scope of the natural product. Some indus- trial advocates of artificial colourings or flavourings insist that it is safer practice than allowing cooks at home to add uncon- trolled substances, bought at the corner shop. Neither natural nor synthetic sub- stances are wholly good or bad. Arsenic and lead, though naturally occuring in food, are toxic to man if taken in certain quantities. Yet certain natural foods con- tain relatively large quantities of these metals. The classic example is shellfish which concentrate higher amounts of arsenic than would be permitted in factory- produced food in almost any country. Authorities charged with controlling the wholesomeness of our food often find it easier to deal with the intentional additives than with contaminants. The economic necessity for using pesticides is undisputed and chemists are working constantly to discover effective compounds that will leave a minimum or no residue at all in the food consumed. The major difficulties arise not in the laboratory but in the field or orchard. Some farmers may feel that if one spraying is good, two will be better and a triple-concentrated dose three times so. There may also be difficulties to enforce the instructions on the use of pesticides, e.g. that apples, for instance, should not be treated in the month before harvest. Packaging materials Not so long ago, pre-packed foods ap- peared either in glass jars or tin cans. Glass is assumed to be practically inert and to pose no problems. Tin cans have, for over a hundred years, been made of sheets of iron or steel, plated with tin on both sides and soldered at the seams. Today, the inside of most cans is coated with a special lacquer; otherwise, during storage, a slow corrosion might take place. Fortunately neither tin nor iron salts are harmful within wide limits; iron is even essential to human health. The most dan- gerous part of the can is the solder which contains a high proportion of lead. Today only two minute areas of solder are nor- mally in contact with the contents but in the last century the whole seam was ex- posed. Hundred-year-old tins of roast veal and carrots were opened and analyzed in a test undertaken in 1938. Despite the heavy deposits of solder on all the seams, the tinned food itself contained almost no lead. This was explained by the fact that, in many food products, lead behaves as a cathode in relation to tin, the latter going into solution and displacing the lead ion which is then deposited in insoluble form. The migration of undesirable substances from packaging materials into the wrap- ped foods presents many problems for food scientists. Recently, complex pack- aging materials have come into use. Many are made of plastics and very few of them are completely insoluble. Plastics behave differently with various foodstuffs. Thus, a plastic container that is not attacked by sugar or acid may be a suitable container for jams. But the unsuspecting housewife may decide to re-use the empty jar for collecting drippings, unaware that certain toxic constituents may now be extracted by the fatty contents. WHO and FAO work closely together on the evaluation of all aspects of food ad- ditives. Joint meetings of experts are held regularly to examine the many facts that must be considered before valid conclu- sions can be formulated. As food stand- ards are set up they become part of the FAO/WHO Codex Alimentarius, a book of food standards that will be accepted even- tually, so it is hoped by the sponsors, on a world-wide basis. As an example—over 70 countries have accepted the Codex standards for milk and milk processing. In efforts to improve nutrition, some categories of food are accorded high pri- ority. They include foods representing a major portion of the diet in one or more countries or in the diet of babies and young children. A baby's digestive system is not just a miniature replica of an adult's —some substances, harmless to an adult, cannot be dealt with by an infant. Further- more, an adult is likely to eat a mixed diet of different types of food, often in- cluding processed foods. On the other hand, mothers who use commercially prepared baby foods for their infants are likely to feed the babies on the same food or the same brand of foods over prolonged pe- riods. These are some of the special prob- lems to be examined by a group of experts meeting this year. For WHO, the motto in the field of food additives is prudence. Adequate tests are needed to determine its safety before per- mitting the use of a new additive. Nor may additives continue to be used despite satisfactory laboratory tests if they cause unfavourable reactions. Recently, doctors reported many sudden cases of a peculiar dermatitis in Holland. The probable cause was discovered to be a new emul- lifier for margarine. Despite the undeni- able technological advantages, its use was quickly abandoned : there are alternative satisfactory emulsifiers available. A recent amendment to the United States Food and Drug Act states suc- cinctly a basic principle it is well to remember: "There are no harmless sub- stances; there are only harmless ways of using them." ■ 22 Faulty nutrition, often linked with problems of metabolism, is a common problem in many deve- loped countries. Physical exercise and special diets are used to cope with it. A clinic in the Nutritional Institute, Moscow. Too much of a good thing ... one man's meat... by M. Rodinson Professor at the Ecole Pratique des Hautes Etudes, Paris. People in glass-houses shouldn't throw stones, nor should the pot call the kettle back, but they do—though more people from different cultures and civilizations are being brought into contact with each other every day. At first sight, any exotic custom may seem arbitrary, barbarous, unnatural or foolish to us, until we perhaps take stock and realize how arbitrary some of our own customs are. Habit has often made us unaware that they were hard to justify originally, though during our childhood we were astonished by the arbitrariness of some of them. This is particularly true of food restric- tions. People don't eat everything that is available to them. In fact, almost every- where, some food or other will arouse dis- gust. A French woman visiting South Amer- ica was served a speciality called iguana, which she found delicious. At dessert she made the mistake of asking what the dish was made of. When she learned that is was the flesh of a lizard she grew pale and suddenly felt quite ill. We can all probably remember an occurrence of this kind. Tur- nips, as far back as I can remember, have always inspired me with intense disgust, yet I would be in great difficulty if I had to explain why. It probably is a conditioned reflex whose origin I have forgotten. The turnip may have been associated with something unpleasant, painful or repulsive that happened to me during my childhood. Almost all of us have had experiences of this kind, although upbringing may suc- ceed in overcoming a repulsion. Many of us have had to resist the assault of our parents who tried to force us to eat some food or other in spite of tears and much grinding of teeth. Some aversions are common to the human race generally, and probably are the result of chemical or physiological reactions of the human body. In the United States,"cafeteria experiments" were carried out, during which children and babies were allowed their choice of a variety of foods. Certain foods were pre- ferred and others rejected, but, by some mysterious intuition, the most dangerous substances were usually set aside. Mistakes may have been made in man's history, but some such mechanism probably was necessary if the human race was to survive. General taboos Man is basically a social animal and it is not surprising, therefore, that most of his aversions result from training rather than from his individual character, or from the fact that he belongs to a given species. There are a number of widespread pro- hibitions. Even though they appear to be "natural", a little study shows that they were learned, because they are to be found only in some societies. A good example is the taboo against eating human flesh. Nothing shows that there is anything wrong with this, physiologically speaking, al- though so far no psychologist apparently has actually offered this meat to children in a "cafeteria experiment". Everyone knows that cannibals do exist, and they do not seem to be any the worse physically or psychologically. It was probably in the interests of preserving the human race as well as the social order that a prohibition was instituted against eating human flesh. However, the prohibition is not universal, and consequently not "natural". There are other widespread taboos which also are not universal. Dog meat, for example, is considered unfit to eat by nu- merous groups, perhaps because the dog was possibly the earliest domesticated ani- mal. Pastoral peoples seem to have observ- ed this taboo more than agricultural peoples, probably because dogs were more useful to the herdsman than to the plough- man. But Europeans did not remain pastoralists for long. Yet this prohibition has become so deep-rooted, so "natural", that in most countries in Europe there is no need for any official means of enforcing it. A large number of food prohibitions serve to set off one ethnic group from another. In Africa, many communities do not eat eggs or chickens. Such cus- toms are usually so deeply ingrained as to be considered natural by the ethnic group in question, who frequently notice neighbouring communities eating foods which they consider disgusting. This fur- nishes an excellent occasion to stigmatize neighbouring peoples as "those who eat impurities". Ancient Greeks visiting East Africa used such distinctions to catalogue people. They described, for example, "bird-eaters", "grasshopper-eaters" and "turtle-eaters", in much the same way as English-speaking peoples today refer jocu- 25 lady to the French as "frog-eaters" or "frogs". Many prohibitions are not general but on the contrary explicit, set forth at length or learned by rote; violations are severely punished. Prohibitions in the past may have characterized an entire people and were rather vague. Later, however, they often were reinforced and given religious authority. In Kafa, in southern Ethiopia, there is a taboo against eating cabbage. In ancient Egypt each nome (independent region) had its prohibitions placed under the authority of a regional god. Ancient Hebrews put great emphasis on listing their prohibitions, and violations would call forth divine punishment. Their legis- lators went far in systematizing food regulations, which can be read in the Pentateuch. As the nationalist religion of the Hebrews became a universalist one, outsiders were permitted to join. Various religions of this expanding type originated at about the same period. One of the later religions, whose origins were in Judaism, Christian- ity, received its "birth certificate" in the decree issued by the Council of Jerusalem. This set out what Christians of non-Jewish origin were allowed to eat, and cut the numerous restrictions of Hebrew law to the minimum. For obscure reasons, per- haps in order to distinguish their religion from the pagan cult of their neighbours, Hebrews had early abstained from pork. Yet the Christian Church allowed this meat to non-Jewish Christians, and later to all Christians. Another religion derived from Judaic sources, Islam, made a differ- ent choice among the Jewish food laws, keeping the prohibition of pork, for exam- ple, but adding a prohibition of wine; all the religions or sects in this part of the world had specific food restrictions. The influence of general or explicit food prohibitions made itself felt in the large universalist religions. Jesus, founder of Christianity, protested against these laws, and proclaimed that it wasn't what went into a man's mouth that defiled him but what issued forth. This did not prevent Christians living in a Moslem environ- ment from adopting, for a certain time at least, a number of Islam's dietary restric- tions. In Europe, Christianity dropped a large number of ancient prohibitions but added others. The Germanic peoples were fond of horse-meat, which was devoured especially during pagan ceremonies. In their combat against paganism, Christian missionaries prohibited the eating of horse- meat under any circumstances. Whether it was because of these prohibitions, or because horse-meat had been confined to pagan ceremonies, the meat became taboo for Europeans generally, and the origins of this custom were forgotten. So deeply did the taboo take root that in the 19th cen- tury there was considerable difficulty in persuading people to eat horse-meat. As a matter of fact, many of our contem- poraries are still averse to it. Prohibition also became a sign of reli- gious affiliation. In India, a Brahmin con- verted to Islam solemnly eats beef, for- bidden by his earlier religion. On the con- trary, if a Moslem becomes a Hindu he proclaims it by publicly eating pork. Milk and meat There are also prohibitions with a time limit, such as the fasts at Lent (Christian) and Ramadan (Moslem). Among many peoples there are prohibitions confined to certain leaders, such as kings or priests. Prohibitions tend to multiply and be- come more complicated when they form part of a ritualized code covering all of human activity. The Bible forbade the Hebrews to eat the kid in its mother's milk, the dish being probably associated with a pagan rite. Later, all mixture of meat and milk was condemned. The original sense had been forgotten, partic- ularly since in the beginning all that was needed was to state that a particular food was prohibited because it was impure, or because God said it was. Later generations provided more rational considerations such as, for example, the claim that "such meat is bad for health" or "has dangerous effects". There are many explanations of this kind. In the past, many attempts have been made to link food taboos, whose origins were unknown, with rational, moral or phil- osophical systems through the interme- diary of divine will. God, or one of the gods, it was declared, wanted man to ab- stain from a given food because He knew it was bad for man or because using it would have immoral consequences (wine, for example). These explanations also indicate ways of getting around some prohibitions which later prove too annoying. Hopefully, this process will continue. Indeed, prohi- bitions whose original meaning or original purpose has been forgotten may constitute serious impediments to economic and social development. The Brahmin pro- hibition against eating beef is often quoted in this context, though this particular question is open to debate. Food prohibitions are a striking exam- ple of the way in which culture modifies nature. Regardless of their origin, they have become a part of our character, our way of life, even our most profound emo- tional reactions. Therefore, rather than make fun of them we must always bear in mind that all of us are ridiculous in some way or other, that the most imposing authorities often subscribe to such arbi- trary codes themselves, and that man can reach his fullest development only as a social being. Thus he has to submit to a number of rules whose origin may remain unknown to him. ■ 26 In Japan, seaweed is regularly harvested by divers who go over the side of these small boats. for the year 2000 by Professor E. J. Bigwood* Finding food for the ever-expanding world population is one of the burning questions of our time. In the following interview, some new means for dealing with it are suggested. W.H.: Does the world produce suffi- cient food at present to sustain its popu- lation? Prof. Bigwood: There is a shortage of food production in comparison with the increase in food requirements. This short- age is particularly pronounced as regards * Director of the Food Law Research Centre, Inst Emeritus Professor of Biochemistry and Nutrition, the production of animal protein; and this shortage is one of the greatest problems as regards the future. In 1958, production was estimated by FAO to be of the order of 20 million tons. In a few years time, requirements will probably reach 40 mil- lion tons, and by the turn of the century about 60 million tons. Therefore produc- tion has to be doubled, and even trebled in a very short time, and one cannot expect, particularly in the case of animal protein, that traditional methods in agri- culture will produce these amounts so rapidly. itute of European Studies, Brussels University. W.H.: So you are rather pessimistic? Prof. Bigwood: I am pessimistic as regards the possibility of meeting the in- creased demand by classical methods of production, mainly of animal proteins. I am afraid, therefore, that if one does not find other methods and new sources of proteins, which would have the same high biological value as animal protein, and could be produced in sufficiently short time, on an industrial basis, the situation might become desperate in ten or twenty years time. 27 mtiritional yl .vcrnivcily must be explored. In addition to all the efforts which have been made so far by the international organizations, we must try to find new sources of protein. Increased production of yeast protein is already underway. Other sources of microbiological origin are developed on certain media and at- tempts have also been made to use the protein from the plankton in the sea. Recent estimates have shown that it is possible to do so, but it means pumping such a lot of sea-water in order to be able to obtain plankton that it seems imprac- tical from the financial point of view. To feed one person ten grams of this new kind of protein would mean pumping 400 tons of sea-water. Clearly that would not be a practical way of solving the problem at present. W.H.: Are there better sources then? Prof. Bigwood: Fortunately, there is another source which I think is extremely important : protein from micro-organisms, which are by-products of petroleum refin- ery. I would like to mention the investi- gations which have been made in France by Champagnat. He showed that this protein is of extremely high biological value and could be used as a food product. If factories could be set up for production of these proteins one could, before the turn of the century, meet the increased requirement of edible protein of high biological value equivalent to that of dou- bling, perhaps even of trebling the 20 mil- lions tons of animal protein which are at present produced throughout the world. W.H.: Why isn't more industrial work being done in this field? Prof. Bigwood: Some is already under way. In addition to the work done by Champagnat, in France, two very power- ful industrial companies are cooperating in the development of a process and have reached the stage where they can test a standardized product on animals. More- over, with the pilot plants already in existence, there could be large-scale deve- lopment in the future. It is about 2,500 times quicker to produce a given amount of protein in that form than to pro- duce meat protein. Much work is also carried out by the Soviet Institute for Basic Organic Compounds; synthetic caviar has already been produced in the laboratory. W.H.: Meat protein then is the luxury protein and this synthetic one would be- come the standard and cheaper kind of protein? Prof Bigwood: That is the technical aspect of the problem. Personally, I am quite sure that prospects justify invest- ments. A company in Holland now syn- thetically produces an important and essen- tial aminoacid, 1-lysine, which contributes to the high biological value of protein. But the technical aspect is not the only one. There are also political and psycho- logical aspects to the problem. The politi- cal aspect, as far as I can see, is that one cannot hope to do anything of this kind in the highly industrialized countries if it is not at the request of the developing coun- tries. Therefore the developing countries and the richer ones must work together. And this leads to the psychological aspect of the problem. I think that we must stop saying the world is going to produce pro- teins and nutrients from new sources for the underdeveloped countries, whereas the populations in the developed countries are going to continue to consume what they are in the habit of consuming beef steak and that kind of superlative food. We must find ways of introducing these new proteins to the highly developed countries. If these new sources are not used in all parts of the world, both the developed and the underdeveloped, then I'm afraid that they will be consumed by nobody. It's for everybody, or it's for nobody. How are we going to introduce these new proteins into food products? That is the problem of the food industry. And I am quite sure that the food industry will come up with the answer in the form of new food products that will appeal to all the people in the world, even in highly developed countries. It must be something 28 which will compete favourably with steak. That is the problem that has to be solved. Speaking generally, a quantitative short- age of total protein exists and something must be done about it. Of course one must also develop the conventional sources of protein of agricultural origin. W.H.: What about the other nutrients? Have we made any progress there? Prof. Bigwood: Of course as regards requirements in calories one can get a greater yield per surface unit of the agri- cultural domain throughout the world by producing more starchy foods. One might, for instance, feed about five to ten more people per square mile by what is called direct food production instead of indirect food production. By indirect production is meant the growing of animal fodder in order to obtain meat, milk, eggs and so on. W.H.: So in fact the animal protein is the one which takes the longest to produce. Prof Bigwood: And it's the least eco- nomical but it has a high biological value. W.H.: And what is the situation regard- ing fats and vitamins? Prof Bigwood: Vitamins, I think, pre- sent no problem, because most of them are now produced synthetically on an industrial scale. It would be much more expensive to produce the same amount of vitamin C as that now manufactured throughout the world, if it were to be produced from natural sources. The industry has, therefore, solved the vitamin problem. As regards fat, the Germans during the war succeeded in producing synthetic fats which turned out to be perfectly digestible. I think that industry can solve this problem much more easily than the protein one. To sum up, what lies in front of us is another great effort on an international level between developed and less devel- oped countries to first solve the political and psychological aspects of the problem. It will then be easier to make the very important investments which are needed to solve technical questions and produce proteins from new sources. ■ Oil can provide protein for man. ocean harvest Unloading a catch of porpoises into fishing boats, Japan. 31 by V. Bogorov* and V. Stepanov** Man's future existence is going to de- pend on the seas and oceans that cover 71 per cent of the globe. The world's population is growing at a rate that may double it in 30 years and may take it to 6,000 million by the end of the century. Present methods of food production can- not keep pace, and new sources must be found. Produce obtained from the sea is already used in the food and textile industries, medicine, agriculture, wine-growing, stock- raising and building construction. Yet only a tiny part of its total resources is exploited. The oceans contain a great vari- ety of organisms, from microscopic single- celled plants to giant whales. At present they yield more than 52 million tons of foodstuffs including 45.7 million tons of fish each year. In terms of protein content, the nutritive value of these 52 million tons corresponds roughly to that of a herd of 200 million cattle. Yet it is only 1 per cent of total world food production. If the sea's resources were used ration- ally, an acre of its surface could produce twice as much protein-rich food as an acre of high-class pasture. Not only is fish a valuable food for man, but its waste prod- ucts and unmarketable varieties can be transformed into products for feeding ani- mals and poultry. Moreover, the sea con- tains several times as much shellfish, crabs, lobsters and other valuable sources of food as it does fish. Hunters of fish Even the most modern fishing techniques do not essentially differ from the methods used by our forefathers who were simple "hunters" of fish. Marine fish culture is still in its infancy. Only a few countries such as Japan and France cultivate shell- fish, certain kinds of fish and crustaceans, and seaweed. By and large, man is still a primitive fish hunter and has not yet evolved to the stage of farming the oceans. Yet shellfish, crabs, lobsters, fish and seaweed could be farmed off-shore in shallow waters. The area of such waters is equal to that of the whole of Europe. In marine as in land farms, weeds and unwanted forms of life would be got rid of and replaced by plants and animals that can serve as food for man and beast. At first sight it may seem difficult for this to be done effectively, yet calculations based on the experience already gained in certain countries show that marine farm- * Corresponding member of the Academy of Sciences of the USSR ** Doctor of the Geographical Sciences ing is one of the greatest potential sources of food. Lakes and rivers also offer great scope. Present production of freshwater fishing is six million tons annually, or 10-12 per cent of the total world fish production. This can certainly be multiplied three or four times in the coming decades. Submarine plant crops Under the influence of sunshine, plants produce organic substances that are es- sential for life. Eighty per cent of the sun's energy reaching the surface of our planet is absorbed by marine plants, and only 20 per cent by land plants. That part of solar energy which is at present ab- sorbed by the natural vegetation in coastal waters could, if applied to marine plants suitable for transformation into human or animal foods, produce a harvest sufficient to feed 58,000 million people. If the total resources of the oceans could be used in the same way, it would be possible to produce four to five times as much, or sufficient food for 290,000 million people. The potential may be even greater still. According to estimates made by the oce- anographer Professor L. Zenkevitch of the Soviet Academy of Sciences, the productive capacity of the sea is more than a thousand times that of the arable land area. As an example, he states that 15 tons of under- water plants can be collected from an area which, on land, could scarcely produce four tons. It must also be remembered that marine vegetation contains four or five times as much organic matter as land plants. It has been calculated that five million tons of vegetable products could be harvested each year in the Baltic, the Black Sea, and the far eastern coastal waters of the Soviet Union. In the opinion of many experts, it will not be long before the introduction of marine plant foods into our daily diet will bring about a revolution comparable to that caused in earlier times by the potato. Seaweed also constitutes an excellent fod- der for domestic animals. It is already being used as fertilizer and as valuable raw material in the food, textile and chemical industries. The resources are there to be exploited. The urgent need is to effect a thorough- going re-organization of the world's fishing industry. Without this any hopes of a rapid increase in food supplies from the sea will be illusory. ■ On an even keel Regardless of where people live, at the ocean's edge or inland, they gener- ally have the possibility of composing a nutritious diet if the economic means are available and knowledge directs them to the best sources. Emphasis on vitamins, unusual sources of protein, or largely untapped resources of the ocean such as seaweed, should not obscure the fact that a balanced diet usually takes care of itself when a fair variety of food of different composition and nutritive value is available. In fact, many nutrition problems have arisen because people have abandoned a well-balanced rural for an imbalanced urban diet. Taboos against certain foods such as eggs or chicken, which are excellent sour- ces of protein, may complicate matters. With a few rare exceptions in the case of well-to-do industrialized communi- ties, striking examples of diet imbalance occur in those parts of the world where food is monotonous and poor in essen- tial elements such as proteins and vita- mins : this is particularly so for popu- lations whose nutrition is based on root crops which contain no more than 2% of protein. However, ignorance often compounds the wrong; the limited re- sources of the budget may be spent on expensive processed, indeed over-pro- cessed, foods and drinks while other less expensive but more nutritious foods are neglected. Dietary balance will be assured if the following proportions are observed : 12-14% of the total daily requirement in calories should be provided by pro- teins, 20-30% by fats, and about 60% by carbohydrates. For growing children, the protein needs are higher than for adults. Pro- tein-derived calories should amount to 15-20% of their daily intake. The average adult requires about 3,000 calories a day, although this amount obviously varies with climate, type of occupation and the individual. A typical balanced daily intake for an adult is given in the table. The first three columns show weights in grams: Lipids and fatty acids Proteins Calories Cereals 400 6.0 40.0 1500 Tuber crops 300 0.8 4.5 210 Vegetables 200 0.8 2.0 60 Fruits 100 0.2 0.5 25 Sugars 40 160 Oils, fats 80 80.0 720 Milk and derivatives 100 3.5 3.5 65 Meat, fish, eggs 180 18.0 36.0 216 Totals 109.3 86.5 2956 These needs could be met, for exam- ple, in the following way: Morning: coffee and milk with two or three slices of bread and butter and jam; Midday : salad, 100 grams of meat, mashed potatoes, fruit; Evening: vegetable soup, two eggs, 100 grammes of macaroni or bread, and a yoghurt. ■ 32 9 Cuba Interactions of nutrition and infection, by N.S. Scrimshaw, C.E. Taylor and J.E. Gordon, Geneva, 1968 (World Health Organization: Monograph Series, No. 57), 329 pages. Price : £2. 14. 0, $9.00, Sw.Fr. 27.00. French, Russian and Span- ish editions in preparation. All doctors and most ordinary people know that an undernourished child is more likely to catch an infectious disease, but it is perhaps less widely recognized that infections may trigger off serious mal- nutrition. This is particularly the case in lesser-developed countries where, to take only one example, measles in under-nou- rished children is often followed by kwash- iorkor, a serious and widespread deficiency disease. Yet only recently have the complex inter- actions between nutrition and infections been studied in detail. The vast body of information now available on this subject has been summarized and evaluated in a new publication of the World Health Organization prepared by three distin- guished workers in nutrition and public health in consultation with 17 specialists in various countries. books Many examples are given of how mal- nutrition, and especially deficiencies of protein and certain vitamins, interfere with the protective barriers that the body normally puts up against the onslaughts of infection. Vitamin A deficiency alone is a factor causing greatly increased suscep- tibility to almost every known infectious disease. One point repeatedly brought out is that malnutrition and infection can be mutually aggravating, and produce more serious consequences for the sufferer than would be expected from a summation of the independent effects of the two. In such cases the result is often fatal. A striking example is the remarkable severity of diarrhoeal disease among "weaning" children in lesser-developed countries, and a whole chapter of the book is devoted to accounts of detailed studies of this situation. Weaning entails two threats to the child's health. First he is exposed to contaminated food after safe breast milk; second, he gets food of poorer quality and often insufficient in quantity for his growing needs. In one study it was shown that, although rates of diarrhoeal disease more than doubled at the begin- ning of the weaning period, the highest rates prevailed during the time when wean- ing was being completed and the child transferred to a completely independent diet. Furthermore, malnutrition resulting from the poor weaning diet increases the chances that acute diarrhoeal disease will prove fatal. "What is definite is that the diarrhoeas occurring at the time of weaning are by far the most important aspect, numerically and as a cause of death, of the general problem of diarrhoeal disease in less deve- loped regions." The authors conclude that "where both malnutrition and exposure to infection are serious, as they are in most tropical and developing countries, success- ful control of these conditions depends upon efforts directed equally against both." 34 Yemen Traveller with Two Passports, by Boris Isa- kov, Novosti Press Agency, Moscow, 1968, 192 pages, 52 kopecks. The author is a well-known Soviet jour- nalist, and he writes about a trip he made under the sponsorship of the World Health Organization to Egypt, the Sudan, Yemen, Irak and Iran. "I spent four months," he says, "visit- ing these countries which were pre- viously unknown to me, where everything was new, different and curious, and where even the problems were special in many fields including that of health." Boris Isakov gives a vivid description of this new world as it opened up before him, its natural beauties, its historic monu- ments, the life of its people, its health prob- lems and all the varied contacts he made. He visited a great number of hospitals, medical schools, medical services and health centres assisted by the World Health Organization both in the cities and in the rural areas. He writes with feeling of the self-sacrific- ing labours of the people who have come from all over the world to help fight disease in the Eastern Mediterranean Region; he describes the courageous en- deavours of the national staff, and all the work undertaken for the protection and promotion of health in these developing countries. This touches many fields extend- ing from the control of communicable diseases to preventive action against the growing risks inherent in certain aspects of the advance of modern civilization. The book contains many concrete examples of the work of the World Health Organiza- tion in the Eastern Mediterranean region. The present medical and health problems of the region are discussed in all their complexity—the acute shortage of doc- tors, the difficulties of providing safe water and developing adequate measures for waste disposal, the need for health edu- cation and many others. In reading Traveller with Two Passports one sees all these health problems through the eyes of a professional journalist who is not himself a medical man. His book will certainly be highly appreciated by that large section of the public that is interested to read of travel in developing countries. Cancer and Public Education, by John Wakefield, London, Pitman Medical Publishing Company, 1962, 106 pages, 27s 6d. Cancer was in the world long before man made his appearance—well-preserved tumours have been found in dinosaur bones at least 80 million years old. It is not surprising therefore that there should be wide-spread, deep-seated fear of this disease or group of diseases against which man has been powerless for millenia. Effec- tive control methods after all are by com- parison something quite recent. The out- look for the cancer patient is increasingly bright today, but early treatment is vital and the ancient fear—abetted by ignor- ance still prevents many patients from seeking treatment early enough. "Delay kills as many people as cancer does" according to one specialist. Knowledge alone does not conquer fear, Wakefield points out in his book. Based on his experience in the Manchester area, he discusses ways and means of changing the climate of public opinion, of changing cancer from "a word that must be whis- pered" to simply the name of one of the many serious diseases that can afflict man. The book is primarily intended to be useful to those who have responsibility for educating the public, and comes out strongly against the use of fear as an instru- ment of propaganda. "Fear of cancer in the past has rarely been the healthy defen- sive mechanism that leads to action : it has been fear of the kind that leads to paralysis of the rabbit in front of the snake. To play on and exacerbate people's anxiety cannot be expected to do other than make them even less likely to behave rationally." Adequate facilities for treatment should be available before propaganda begins, the reassuring aspects of modern treat- ment should be stressed, but exaggerated claims for cancer cures should be avoided, and propaganda should take existing be- liefs and prejudices into account—these are among the maxims advocated. Wakefield's argument more than streng- thens the suspicion that a great deal of scare propaganda today about cancer, cigarette smoking and similar topics is wasted. ■ Photo credits WHO/P. BOUCAS : Front cover WHO/D. HENRIOUD : p. 3 WHO/B. ZEPPILLI : pp. 5, 11, 21, 24, 25, 32 WHO/T. FARKAS : p. 5 R. VIOLLET : p. 7 L. SIRMAN (c): pp. 4, 9, 24, 27, 30, 31 WHO/F. J. TOMICHE : p. 9 WHO/SPOONER: pp. 10, 1 I WHO: pp. 12, 13, 15, 33 WHO/R. GRAMICCIA : p. 13 J. NIEPCE (C): p. 17 INTERFOTO MTI : pp. 17, 19, back cover WHO/M. JACOT : p. 23 WHO/J. MOHR: p. 28, back cover WHO/P. ALMASY : pp. 29, 33 WHO/E. RICE: p. 34 WHO/B. MOSS: p. 35 N• No" ' :4"-•• E THE WORLD HEALTH ORGANIZATION IN 1969 WHO AND PALERONIA paleronia is a composite of several WHO member countries. It is not rich, not poor, not highly industrialized and not one of the newly independent states. Its health situation has some features of countries in all these categories, however, and its Government and people participate in many different ways in co-operative international health work. On 18 September 1948, Paleronia, a country of some 29 million people, became the 55th Member of the World Health Organization (membership reached 131 by January 1969). This was too late for the country to take part in the First World Health Assembly, held in Geneva that year, but in 1949, at the Second Assembly, in Rome, Paleronia was represented by a delegate with full voting rights. In his maiden speech, he described his country's health situation and expressed its desire to contribute to the realization of WHO's aims. During the three weeks of the Assembly, he had interesting private conver- sations with other delegates about health matters of common interest. He also met members of the WHO Secretariat, including the Director-General and some of the technical staff, as well as observers from the United Nations and other organizations of the urr family. On his return home, the Paleronian delegate made a report to his superior, the Under-Secretary of State for Health and Director of the Health Department, then a section of the Ministry of the Interior. The Under-Secretary, a lawyer with a promising political future, had learned most of what he knew about health from his two deputies : one, the delegate to the Assembly, was chief of preventive medicine; the other was in charge of hospitals. Finding the money The Under-Secretary was pleased at the prospect of getting help from WHO to build up Paleronia's health services but a 2 little concerned about the reaction of the Minister of Finance to the news that the Government would have to pay $58,620 as its share of the WHO Regular Budget for 1950, which totalled $7,501,500 (in 1969 it is $62,000,000).* He also learned that voio intended to decentralize its work and that for this purpose the world had been divided into six geographical regions ", each with its own regional organization. The region to which Paleronia had been assigned was not yet functioning at full strength, but the Regional Director and some of the advisers had been appointed, and discussions about the kind of aid that WHO might give could begin at any time. The first person from WHO to visit Paleronia in an official * WHO also administers funds from the UN Development Programme (Technical Assistance and the Special Fund) and voluntary contributions from governments, institutions and private persons. It has joint programme arrangements with UNICEF and other organizations. ** See back page for addresses of wHo headquarters and regional offices. capacity was a member of the regional office staff, invited by the Government to help in taking stock of health needs. The adviser, a public health man, was taken to see hospitals, clinics and health centres in the largest cities (there wasn't much to show him in the rural areas) and introduced to officials, doctors and health officers who could give him first-hand impressions of the country's health problems. He also studied the available health statistics mostly figures on births, causes of death and common diseases. Pinpointing problems Although the statistics were incomplete, the adviser reported back to the regional office that the main health problems of Paleronia, a country with a few specialized industries and large agricultural areas supporting between 70 and 80 per cent of the population, seemed to be communicable diseases and a rela- tively high infant mortality. 3 Infections were an important cause of death—a reflection of poor sanitary conditions, such as unsafe water and inadequate waste disposal. The most prevalent diseases were tuberculosis and the afflictions of childhood— measles, whooping cough, diphtheria, poliomyelitis, malnutrition and diarrhoeas. There was a good deal of trachoma, especially in the rural areas, and malaria outbreaks were frequent in the southern part of the country. This situation accounted for the high infant mortality rate (about 4 times as much as Sweden) and the equally high death rates of young children and of mothers in child- birth. Projects are born There was a serious shortage of physicians. The country had 2,000 doctors in all, most of them established in the cities, aggravating the lack of medical services in the rural areas. Other health personnel were also insufficient. A modest number of nurses and midwives were available but, generally speaking, their training was sadly deficient by modern standards. There were some dentists, pharmacists and sanitarians, and, in spite of the prominent place of agriculture and animal raising in the coun- try's economy, only a handful of veterinarians. The two largest cities had medical schools but most of the graduate doctors were obliged to go abroad for specialization. There were about 1.6 hospital beds for each 1,000 of the population (counting the two mental hospitals and the TB sanatorium), 150 out-patient clinics, 250 rural health centres and 870 dispensaries. Everyone was agreed that efforts should be made to raise the of status the Department of Health of Paleronia to that of a ministry, so that health would be accorded more prestige and perhaps a bigger budget. The wHo adviser indicated that wHo would provide the necessary funds for a senior officer of the Department to visit other countries and study the organization of their health services, if the Government so wished. He thought that priority should be given to malaria control and to mother and child health services. Some sort of a training scheme was necessary to increase the numbers of available health personnel but that would take a little more study and, in any case, training was implicit in all wHo-aided programmes. Thus, three projects—maternal and child health, malaria, and a fellowship for travel study—were included in the budget proposed to the WHO Regional Committee (composed of representatives of countries of the Region) at the first of its annual meetings. They were approved, along with a number of projects for other coun- tries of the Region, and the entire budget was forwarded to the wHo Director-General in Geneva. There it was consolidated into the programme and budget proposal for the entire Organization, reviewed by the wHo Executive Board* and presented to the dele- gates at the World Health Assembly. Paleronia's projects survived this detailed examination, and recruitment of the international staff needed to get them started was begun immediately afterwards. The time of action Meanwhile the Under-Secretary of Health of Paleronia had been active. His Department was promoted to the rank of * Each year the World Health Assembly elects eight countries to design- ate as many persons to serve for three years on the WHO Executive Board, which now has 24 members. 4 In the waiting room of a mother and child health centre. ministry (with himself as the Minister of Health), the chief of preventive medicine was made Director of Health Services and put in charge of all health work, preventive and curative. He then went abroad on a short WHO study fellowship and came back full of ideas but a little discouraged about the possibilities of carrying them out. UNICEF agreed to help the maternal and child health project with equipment for a demonstration mai centre. WHO recruited a doctor who was a specialist in maternal and child health, and a public-health nurse-midwife, each for two years, by which time it was hoped that their Paleronian opposite numbers would be able to take over. It was decided to study the child feeding habits to try to find the reason for the obvious malnutrition that weakened babies and made them susceptible to infection. Steps were also necessary to improve hygiene and thus prevent the spread of disease. The wno-assisted malaria control project also received help from UNICEF, mostly DDT and spraying equipment, to kill mala- ria-carrying mosquitos. Some transport was supplied, since the malarious areas of the south were difficult to reach. The next year, a health demonstration area was set up in a country district not far from the capital where practical training could be given to the many different kinds of health workers needed in the country. Medical students, nurses, midwives, sanitarians and health statisticians did part of their field work there. Equally important, there was a training school in the area for auxiliaries whose functions would be to relieve the pressure on over-burdened professional staff. The new Ministry of Health began to expand. The general 5 administrative machinery was reorganized, staff increased, the work in endemic diseases strengthened and sections added for nursing and for maternal and child health. Tuberculosis and venereal diseases were given more attention, and posts were created to provide supervision and technical guidance for new activities. The collection and analysis of health statistics were improved so that the relative importance of the different health problems could be assessed. Avxo provided a public health admin- istrator who had an office in the Ministry of Health for several years and was available for consultation about these changes. He was joined for a time by a sanitary engineer who advised the Government on measures to improve environmental hygiene and helped to organize a training school for sanitarians. New role in Assembly The Paleronian delegation to the World Health Assembly was gradually increased to three, with the Director of Health Serv- ices usually the chief delegate, except on the rare occasions when the Minister himself attended. There were informal technical discussions during the Assem- bly each year on a subject of common interest. When "nursing" was the topic, the chief nurse of Paleronia was added to the delegation as an adviser so that she could contribute her country's experience to the discussions. She had earlier been given a fellowship * by wilo and had gone abroad to follow a post-graduate course in nursing and hospital administration. The Director of Health Services was increasingly active in the Assembly. He was elected to office several times (one year as Chairman of the Programme and Budget Committee) and served a three-year term on the wHo Executive Board, which meets twice a year to carry out the Health Assembly's decisions, review the Director-General's proposed programme and budget for the next year, and forward it to the Assembly with com- ments and recommendations. On the Board he did not vote on behalf of Paleronia, as in the Assembly, but expressed his opinion as an independent health expert. Malaria attack stepped up The delegate of Paleronia was one of the promoters of the movement in WHO to drop malaria control, which promised to be an unending task since re-infection was so common, and to launch an all-out concentrated campaign to eradicate malaria from the face of the globe. At the Eighth World Health Assem- bly in 1955, where malaria eradication ** was adopted as the WHO policy, he made a convincing speech in favour of this step. * WHO devotes a large part of its resources to the education of health workers through fellowships, by the creation of teaching institutions, and by providing teachers and other staff. Specialized training courses are given and seminars arranged for the exchange of ideas and information. ** Areas inhabited by more than 1,359 million people-80 per cent of the inhabitants of the originally malarious areas of the world—have now been freed from the risk of malaria. 357 millions still lack this protection. 6 To stop malaria transmission, all houses are numbered and regularly sprayed with insecticide. There was a good deal of self-interest in this. Paleronia had managed, with wno help, to reduce malaria to a point where it was no longer a serious problem. But the cases that still occurred were difficult to get at and there was always a chance that they would touch off an epidemic, since certain parts of the country were infested with the mosquitos that keep up the chain of infection. Such areas are vulnerable as long as malaria exists in other parts of the world. Complete eradication must be the aim. Paleronia's central laboratory services which had been reor- ganized and developed were now helping to fight malaria. Blood from each person with an unidentified fever was sent for analysis so that carriers could be traced and treated. The increased numbers of people with public health training and experience had brought about other changes. More and more attention was being given to the rural areas and the central office of health had difficulty supervising the new activities. Eventually health directors were appointed in each province, who had a certain degree of autonomy in carrying out their work. After several years they began to play a strong hand in planning their own programmes. The country's economic development of the late fifties and early sixties was reflected in the Ministry's increased financial resources. Grants were made to training schools and universi- ties. Two new medical faculties were opened, with technical help from wno. More and more staff of the health services were given post-graduate and general public health training. Some went abroad for specialized courses or to learn about the health services of countries that had passed through the same stage of development earlier. 7 Health and water During those years it became obvious that health depends on many factors that are outside the realm of a health ministry. One region of Paleronia was little developed because of lack of water. A canal was built bringing water from a large river in another part of the country, and this opened up the area for new settlers. The project provided an opportunity to apply much new knowledge in the social sciences. Not only were the poten- tial health hazards studied in advance, but the habits and cus- toms of the immigrants were taken into account in preparing the new settlements. Particular attention was given to the snail population to see if there were species in the area that could transmit schistosomiasis, a debilitating disease. This in fact proved to be the case and although preventive measures were taken, schistosomiasis was brought into the area by labourers working on the canal who infected its waters and the potential snail carriers. Small foci of infection appeared here and there that are still a problem. The precautions taken were insufficient. The Government was continually preoccupied with the water problem in some form or other. Great efforts were made to ensure that all the villages were supplied with piped water, efforts that are still continuing. In the capital city the water supply was not only inadequate for the growing population but also unsafe. WHO made a pre-investment study of the city's needs and supervised the drawing up of plans for an efficient waterworks system, financed with the help of $3,000,000 from the UN Special Fund. In 1965, one of the prominent public health administrators of Paleronia was seconded by his Government to work with Snails play an essential part in the transmission of schistosomiasis. 8 WHO *. He was assigned to another wHo region where his task was mainly to help countries less developed than his own to improve their health services. His credentials for the post were 15 years of struggle with disease and with administrative prob- lems in Paleronia. During that time, the population of Pale- ronia had increased by about 30 per cent for, although less babies were born, more of them survived and went on to healthy childhood: also fewer mothers were dying in childbirth. Another important factor, deaths from infectious diseases had dropped to nearly a fifth of the former figure. This situation reflected improvements that had taken place in housing, sanitation, nutri- tion and education, and not only direct action on the part of the Ministry of Health. About this time, the public health adviser to the Government had been replaced by a WHO Representative who co-ordinated all health projects assisted by WHO and kept in touch with the activities of other UN bodies that concerned WHO in any way. An applied nutrition programme jointly aided by FAO and WHO was one of these. An unsuspected problem But the problems were not all solved. Health services were still under-staffed in spite of the training programmes, and chron- ic diseases demanded more and more attention. With advances in medical science and better facilities, more heart disease and cancer were being diagnosed. An analysis of national health statistics revealed that a peculiar form of cancer was common, * The vvxo Secretariat is composed of 4,400 persons of more than 90 nationalities. City health problems are discussed at the Ministry. 9 the importance of which had not been suspected before. This came to the attention of WHO headquarters where, under the Programme of Medical Research, a world-wide network of international reference centres had been organized to aid cancer research. Data from studies made at these reference centres and their collaborating laboratories throughout the world were collated and analyzed in Geneva and at the Inter- national Agency for Research on Cancer in Lyons * for the benefit of all research workers, everywhere. Similar methods had been adopted to investigate cardiovascular diseases and many other unsolved health problems. Paleronia agreed to collaborate in the cancer research programme. An outstanding specialist from the country was asked to participate in the studies and to serve on the WHO Expert Panel on Cancer**. He was once a member of the Expert Committee on Cancer that met to advise the WHO Director-General on newest methods of diagnosis. * The International Agency for Research on Cancer was established by the World Health Assembly in 1965 with headquarters in Lyons, France, to concentrate on problems of environmental carcinogenesis in man. Contributing countries are Australia, Federal Republic of Germany, France, Israel, Italy, Netherlands, USSR, UK and USA. ** Some 2,600 scientists and health administrators from many nations in different branches of medicine and public health are members of 43 wpio expert panels on various health questions and are available to give WHO the most authoritative technical advice. Expert committees are chosen from these panels when the need arises. Members contribute their services to WHO and bring together latest information in a given field. Reports are usually published. The Advisory Committee on Medical Research, consisting of distinguished scientists of diverse backgrounds including a number of Nobel Prize winners, meets once a year to review the Organization's Medical Research Programme. Research and development Paleronia did not favour the expansion of WHO's research efforts when the idea was first discussed at the Health Assembly. Its chief delegate said that his country felt that medical research should be left to the highly industrialized countries that had plenty of money, instead of spending WHO's limited resources on such a luxury. His country and especially the newly-inde- pendent countries needed all the help WHO could give them to fight infectious diseases and malnutrition, and to build up their struggling health services. As the argument progressed, however, it appeared that research was needed not only on the so-called problems of civi- lization—cancer, heart disease and geriatrics but also on some of the oldest diseases known to man. Mosquitos were becoming more and more resistant to chemicals used in the malaria erad- ication campaign and new ways of dealing with them had to be found. Smallpox eradication, also a policy of WHO, was not as simple as it had first appeared to be. Effective vaccines in use for a hundred years had eliminated smallpox from a number of countries, yet they quickly lost their potency in the tropics where the disease was still endemic. Stable, freeze-dried vaccines soon promised to overcome this difficulty but other prob- lems had come up in the course of the eradication campaign that could only be solved by both fundamental and applied research. Another important point of view put forward was that afflic- tions like cardiovascular diseases which seemed to be typical of the industrialized world were becoming more and more 10 A lecture by a visiting WHO professor. important in developing countries as endemic infections re- treated. Studying them under unfamiliar conditions could con- tribute to the general sum of knowledge and benefit countries at all stages of development. There were also many aspects of the population question that needed investigation so that WHO could give sound advice to countries asking for help on the various aspects of human repro- duction. Overpopulation was not a problem in Paleronia but the government wanted assistance to extend its maternal and child health services to include family planning, believing that the better spacing of children would help to reduce infant and maternal deaths. Taking all these circumstances and many others into consid- eration, Paleronia finally decided to support the WHO Medical Research Programme, particularly since it was clear that WHO would not spend money on expensive laboratories and equip- ment but would use the facilities of institutions and universities throughout the world, gathering data on the same problem observed in many different circumstances and co-ordinating the results on the international level in a way that would be impos- sible for any one country. Twenty years of work In 1968, the year that WHO's Twentieth Anniversary was celebrated, officials in Paleronia took stock of the health situa- tion in order to be able to make a statement to the World Health Assembly. Although conscious that much remained to be done, they were quietly pleased with what emerged. Condi- 11 tions all over the country were better than they had been in 1948. There were more trained people—doctors, nurses, mid- wives, sanitarians and veterinarians, as well as auxiliaries in all these fields. Two new medical schools had been established in provincial capitals, with some help from WHO, and public health was inte- grated into the curricula. A school for sanitarians was affiliated to one of them and used some of its facilities. Where there had been no specialists in pediatrics, there was now a small group whose competence was becoming known abroad (wHo sent a professor of pediatrics to Paleronia for a year and awarded several fellowships for study in more advanced countries). Nevertheless, there were still serious gaps in the health ser- vices available to the people, mainly because of lack of sufficient trained personnel and of money. The situation was being ana- lyzed with the help of a vsmo health planning expert and an economist, and it was hoped that a long-term programme for the rational development of the country's health services could be drawn up that would be acceptable to the Govern- ment and incorporated into the country's social and economic plan. In addressing the Assembly on this subject, the delegate of Paleronia gave much credit to WHO for its role in making these achievements possible—perhaps too much. He spoke warmly of WHO's work in the co-ordination of international research and the exchange of information on health matters in general. Countries like his own had come to depend greatly on wHo technical services—the publications covering many aspects of health, the guidance in the collection and utilization of health statistics, the epidemiological surveillance and quarantine ser- vice, the standards set for the quality and purity of drugs and of biological substances used in the prevention and treatment of disease—all activities, he felt, that were the especial province of an international health organization. The delegate also took the opportunity of mentioning a few things that Paleronia would like from WHO in the future includ- ing help with setting up a dental health service and technical assistance on control of pharmaceutical preparations, but did not fail to pledge his country's support for the Organization's aims and programme in the future. WHO ADDRESSES Headquarters: wHo, Avenue Appia, 1211 Geneva, Switzerland Regions: Africa: P.O. Box 6, Brazzaville, Republic of the Congo Americas: Pan American Sanitary Bureau, 525, 23rd Street, N.W. Washington, D.C., 20037, USA Eastern Mediterranean: P.O. Box 1517, Alexandria, United Arab Republic Europe: 8 Scherfigsvej, Copenhagen 0, Denmark South-East Asia: World Health House, Indraprastha Estate, Ring Road, New Delhi-1, India Western Pacific: P.O. Box 2932, Manila, Philippines 12